Basal Cell Carcinoma

What is a Basal Cell Carcinoma?

Basal Cell Carcinoma also referred to as BCC, is the most common cancer in Australia. They account for around 80% of all non-melanoma skin cancers. In 2016 it is estimated that there were 600,000 Basal Cell Carcinomas.

When treated early the vast majority of Basal Cell Carcinomas are not life-threatening.

Basal Cell Carcinomas are malignant, abnormal, uncontrolled growths or lesions that arise in the skin’s basal cells, which line the deepest layer of the epidermis (the outermost layer of the skin).

Basal Cell Carcinoma Risk Factors

Anyone with a history of sun exposure can develop Basal Cell Carcinoma. However groups of people at greater risk include:

Fair Skin Types - people who are at highest risk have fair skin, freckles, blond or red hair, and blue, green, or grey eyes. They have a tendency to burn rather than tan

Prior Skin Cancer - People who have had one Basal Cell Carcinoma are at risk for developing others, in the same area or elsewhere on the body. If you’ve had a Basal Cell Carcinoma you have a 10 times higher risk of developing another skin cancer of any type and so routine reviews are advised on a 6 monthly basis.

Family History - The tendency to develop Basal Cell Carcinoma may also be inherited

Older People - Those most often affected are older people, but as the number of new cases has increased sharply each year in the last few decades, the average age of patients at onset has decreased. The disease is rarely seen in children, but occasionally a teenager is affected.

Occupational - Workers in occupations that require long hours outdoors

Recreational - People who pursue outdoor recreation activities for hours at a time

Where Are Basal Cell Carcinomas Found?

They can appear anywhere on the body but most commonly develop on parts of the body that receive high or intermittent sun exposure (head, face, neck, shoulders and back).

What Causes Basal Cell Carcinoma?

95% of Basal Cell Carcinomas in Australia are the result from skin damage caused by

Cumulative long-term sun exposure

Intermittent overexposure to ultraviolet (UV) radiation from the sun (typically leading to sunburn)

Most Basal Cell Carcinomas occur on parts of the body exposed to the sun — especially the face, ears, neck, scalp, shoulders, and back, but many can be found in areas that are only burned or exposed occasionally - such as the abdomen or upper thighs

It is not possible to pinpoint a precise, single cause for a specific tumour, especially tumours found on a sun-protected (un-exposed) area of the body or in an extremely young individual. Some Basal Cell Carcinoma can also result from less common causes such as:

contact with arsenic,

exposure to ionising radiation such as X-rays (used in radiotherapy)

open sores that resist healing,

chronic inflammatory skin conditions, and

as complications of burns and scars.

Symptoms of Basal Cell Carcinoma?

Basal Cell Carcinoma may have no visible symptoms and tends to grow slowly without spreading to other parts of the body, but if it has progressed to the skin’s upper layers a tumour will typically have some visible clues. A key factor used to identify it is ongoing change that persists beyond a few weeks in a lesion on the skin.

If you observe two or more of the signs below, you should consult the Bondi Junction Skin Cancer Clinic immediately.

An open sore that bleeds, oozes, or crusts and remains open for a few weeks, only to heal up and then bleed again. A persistent, non­–healing sore is a very common sign of early Basal Cell Carcinoma

A reddish patch or irritated area, frequently occurring on the face, chest, shoulders, arms, or legs. It may develop a crust. It may itch or hurt. Mostly they produce, no

discomfort and local tenderness.

A shiny bump or nodule that is pearly or clear and is often pink, red, or white. The bump can also be tan, black, or brown, especially in dark-haired people, and can be confused with a normal mole.

A pink growth with a slightly elevated rolled edge and or take on a donut shape. The growth slowly enlarges, tiny blood vessels may develop on the surface.

A scar-like area that is white, yellow or waxy, and often has poorly defined borders; the skin itself appears shiny and taut. This warning sign may indicate the presence of an invasive Basal Cell Carcinoma that is larger than it appears to be on the surface.

Stages of Basal Cell Carcinoma

Basal Cell Carcinomas are usually slow growing, occasionally BCCs grow in subtle ways and may be quite extensive and advanced by the time of diagnosis. Some BCC’s are aggressive and can grow and spread (metastasise) quickly.

If BCC cancer is advanced the outcome (prognosis) can vary and affect your treatment choices. A small number of Basal Cell Carcinomas cases can be fatal.

Basal Cell Carcinoma Screening

Diagnosis and management of Basal Cell Carcinoma is best performed via a Full Body Scan.

In the first incidence, this process includes

Digitally Mapping a patient's entire body for any suspicious skin damage or lesion

Followed by a detailed Dermoscopic Examination by a trained skin cancer specialist

Recording and combining all images and skin metrics (size, shape, colour, and other attributes) into the patient record

Basal Cell Carcinoma Diagnosis

Occasionally a punch or shave biopsy may be required to confirm the diagnosis and to guide effective treatment. This diagnostic process involves a Doctor taking a tissue sample for biopsy by removing a portion of the lesion with a biopsy punch or by scraping the lesion with a curette (an instrument with a sharp ring-shaped tip).Usually a biopsy is sufficient to establish the diagnosis of a Basal Cell Carcinoma. In the rare case of suspected metastatic Basal Cell Carcinoma, lymph nodes may be examined by the Doctor to see if the cancer has spread or by the use of imaging technologies like ultrasound, CT, or PET scanning.

Untreated Basal Cell Carcinomas

Basal Cell Carcinomas seldom spread to vital organs and respond well to early treatment. If untreated the consequences could include:

Disfigurement

Nerve, or muscle injury, or other injury to nearby structures like eyelids

Certain rare, aggressive forms can be lethal if not treated promptly.

The larger the tumour has grown, the more extensive any surgical treatment would be. This could result in increased scarring.

In 2016 it is estimated that there were 560 deaths in Australia from non-melanoma skin cancers. It is not possible to identify how many of these are Basal Cell Carcinomas as this data is not separately recorded.

Basal Cell Carcinoma Treatment Options

Surgical Removal for Basal Cell Carcinoma

Surgical removal of the Basal Cell Carcinoma is the most common treatment. Non-melanoma skin cancers are almost always surgically removed under local anaesthetic. This approach offers:

The highest cure rates

Is immediate,

Lesions margins are checked to confirm complete clearance

In more advanced skin cancers, some of the surrounding tissue may also be removed to make sure that all of the cancerous cells are cleared.

Excision Treatment Process - After careful administration of local anaesthetic, the Doctor uses a scalpel to remove the entire growth, along with surrounding apparently normal skin as a safety margin.

The wound around the surgical site is then closed with sutures (stitches).

Excision Treatment Recovery - For a few days post excision there may be minor bruising and swelling. Scarring is usually minimal. Pain or discomfort is minor.

Typically, where sutures are used, they are removed soon afterwards.

Surgical Excision Prognosis - Studies indicate the cure rate for primary tumours with this technique is about 92 percent. This rate drops to 77 percent for recurrent Basal Cell Carcinomas.

A repeat excision may be necessary on a subsequent occasion if evidence of skin cancer is found in the specimen.

Combination Therapy for Basal Cell Carcinoma

At the Bondi Junction Skin Cancer Clinic we may recommend combination therapy to treat the Basal Cell Carcinoma. Some combinations are:

Topical Chemotherapy - Imiquimod for Basal Cell Carcinoma

This is a prescription only cream and is approved for the treatment of biopsy-proven superficial Basal Cell Carcinomas that are not otherwise suitable for surgical removal, but is not appropriate for use on invasive Basal Cell Carcinomas.

Topical Chemotherapy Treatment Process - Before administering the cream, the patient should clean and moisten skin (at the most), once clean and moist, the treatment can be administered by the patient themselves or by a Registered Nurse at our Clinic

Topical Chemotherapy Treatment Recovery - Expect some minor pain, redness, swelling, crusting up ‘like a pizza’. It is a non invasive treatment but can be highly unsightly and cause pain for up to 2 months.

PhotoDynamic Therapy for Basal Cell Carcinoma

Photodynamic therapy (PDT) involves the use of photochemical reactions mediated through the interaction of photosensitizing agents, light, and oxygen for the treatment of superficial Basal Cell Carcinoma. It is especially useful for larger superficial Basal Cell Carcinomas on the face and scalp.

Cancerous cells accumulate more light absorbing cells (porphyrins) than normal cells that when exposed to certain light wavelengths potentiates a beneficial chemical reaction. It is this principle that underpins the use of PDT for such tissues.

The First Step: involves the application to the target growths cells with a photosensitizer in the form of a chemical agent that reacts to light such as Aminolevulinic Acid (ALA) or methyl aminolevulinate (MAL). Curettage is needed to destroy epidermis to allow egress of sensitising cream into lesion for 1 hour under occlusion

The Second Step: involves the activation of the photosensitizer in the presence of oxygen with a specific wavelength of light directed toward the target tissue. The photosensitizer is preferentially absorbed by cells that are dividing (which occurs at a greater rate in Actinic Keratoses) and when the light source is directed to the affected areas of skin. This leads to activation of protoporphyrins and inflammation and destruction of the lesion.

It may not be suitable for all patients with BCC’s. The process is invasive, and can be very painful when the light is applied and for a day post treatment, and the curettage will scar.

The approach offers less scarring than surgical excision, and is more suited to larger superficial lesions than surgery, and can be used as a field treatment for areas with multiple small Basal Cell Carcinomas. Success rates are highly operator dependent.

Common side effects are redness, pain, bleeding, and swelling.

PhotoDynamic Therapy Treatment Recovery - After treatment, patients become locally photosensitive for 48 hours where the light-sensitizing agent was applied, and must avoid both outdoor and indoor light and be careful to use sun protection

PhotoDynamic Therapy Treatment Prognosis - 70-80% cure rate. Can mask the presence of residual disease and so delay successful treatment so initial biopsy is strongly advised to assess the invasive potential of any Basal Cell Carcinoma prior to PDT being commenced.

Recurrence rates vary considerably (from 0 to 52 percent), so the technique is not currently recommended for invasive Basal Cell Carcinoma

General Prognosis After Treatment for Basal Cell Carcinoma

An individual's prognosis depends on the type and stage of cancer, as well as their age and general health at the time of diagnosis. The majority of Basal Cell Carcinoma cancers are successfully treated.

When small Basal Cell Carcinomas are removed, the scars are usually cosmetically quite acceptable. If the tumours are very large, a skin graft or flap may be used to repair the wound in order to achieve the best cosmetic result and facilitate healing.

Basal Cell Carcinoma Recurrence

Doctors at the Bondi Junction Skin Cancer Clinic have seen a significant increase in the number of patients in their twenties and thirties are being treated for Basal Cell Carcinoma over the last 17 years.

Men with Basal Cell Carcinoma have outnumbered women with the disease, but more women are getting Basal Cell Carcinomas than in the past.

Regular checks at the Bondi Junction Skin Cancer Clinic should be performed so that not only the site(s) previously treated, but the entire skin surface can be examined, and mapped digitally and compared to the images taken at subsequent skin checks.

Basal Cell Carcinomas on the scalp and nose are especially troublesome, with higher rates of recurrence and with these recurrences typically taking place within the first two to three years following surgery.

Should a cancer recur, your Doctor might recommend a different type of treatment. Some methods, such as Mohs micrographic surgery, may be highly effective for recurrences.

Basal Cell Carcinoma Prevention

Anyone who has had one Basal Cell Carcinoma has an increased chance of developing another, especially in the same skin area or nearby. That is usually because the skin has already suffered irreversible sun damage.

Thus, it is crucial to pay particular attention to any previously treated site, and any changes noted should be shown immediately to your Doctor at the Bondi Junction Skin Cancer Clinic.

Basal Cell Carcinomas on the nose, ears, and lips are especially prone to recurrence.

Even if no suspicious signs are noticed, regularly scheduled follow-up visits including total-body skin exams are an essential part of post-treatment care every 6 months.

To prevent Basal Cell Carcinoma make sure you follow the recommendations below:

Seek the shade, especially between 10am and 3pm when UV levels are most intense

Avoid sunburn by minimising sun exposure when the SunSmart UV Alert exceeds 3 and especially in the middle of the day in the warmer half of the year

Avoid tanning and never use UV tanning beds

Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses

Use Nicotinamide (Vitamin B3) 500mg twice a day unless contraindicated

Use a broad spectrum (UVA/UVB) sunscreen with an SPF of 30+ or higher every day. For extended outdoor activity, use a water-resistant, broad spectrum (UVA/UVB) sunscreen with an SPF of 30+ or higher

Apply sunscreen to your entire body 10 minutes before going outside. Reapply every two hours or immediately after swimming or excessive sweating, or towelling down

Keep newborns out of the sun. Sunscreens should be used on babies over the age of six months

Examine your skin head-to-toe every month looking for unique changes.

If you see unique changes anywhere and of any kind, keep an eye on it and if it continues to change for more than 2-3 weeks the notify the Bondi Junction Skin Cancer Clinic without delay.